﻿<%@page import="com.cchr.acms.model.Action"%>
<%@page import="com.cchr.acms.model.AbuseType"%>
<%@page import="com.cchr.acms.util.HtmlComponentUtil.SelectOption"%>
<%@page import="java.util.List"%>
<%@page import="com.cchr.acms.util.HtmlComponentUtil"%>
<%@ page language="java" contentType="text/html; charset=UTF-8"   pageEncoding="UTF-8"%>
<%@ taglib prefix="c" uri="http://java.sun.com/jsp/jstl/core"%>
<%@ taglib uri="http://java.sun.com/jsp/jstl/fmt" prefix="fmt" %>
<%
	String contextPath = request.getContextPath();
%>
<!--[if IE 8]>         <html class="ie8"> <![endif]-->
<!--[if IE 9]>         <html class="ie9 gt-ie8"> <![endif]-->
<!--[if gt IE 9]><!--> <html class="gt-ie8 gt-ie9 not-ie"> <!--<![endif]-->
<style type="text/css">
.page-signup-alt .panel{
width:40%;
margin:0 auto;
padding:27px}
</style>


<!-- 1. $BODY ======================================================================================
	
	Body

	Classes:
	* 'theme-{THEME NAME}'
	* 'right-to-left'     - Sets text direction to right-to-left
-->

	<!-- Form -->
	
	<form class="panel form-horizontal" id="jq-validation-form" method="POST" style="width:1000px">
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header">Information on the Person Abused:</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">First Name</label>
					<label class="form-control">${caseInfo.abusedPerson.firstName}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Middle Name</label>
					<label class="form-control">${caseInfo.abusedPerson.middleName}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Last Name</label>
					<label class="form-control">${caseInfo.abusedPerson.lastName}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label">Street Address</label>
					<label class="form-control">${caseInfo.abusedPerson.streetAddress}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">City</label>
					<label class="form-control">${caseInfo.abusedPerson.city}</label>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">State/Province</label>
					<label class="form-control">${caseInfo.abusedPerson.state}</label>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Zip/Postal Code</label>
					<label class="form-control">${caseInfo.abusedPerson.zip}</label>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Country</label>
					<label class="form-control">${caseInfo.abusedPerson.country}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Phone Number</label>
					<label class="form-control">${caseInfo.abusedPerson.telephone}</label>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Email Address</label>
					<label class="form-control">${caseInfo.abusedPerson.email}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Birth Date of Abused</label>
					<label class="form-control"><fmt:formatDate value="${caseInfo.abusedPerson.birthDay}" pattern="MM/dd/yyyy"/></label>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Or approx. Age</label>
					<label class="form-control">${caseInfo.abusedPerson.age}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label">Approximate Date Abuse Occurred</label>
					<div id="bs-datepicker-range" class="input-daterange input-group">
						<label class="input-sm form-control"><fmt:formatDate value="${caseInfo.caseStart}" pattern="MM/dd/yyyys"/></label>
						<span class="input-group-addon">to</span>
						<label class="input-sm form-control"><fmt:formatDate value="${caseInfo.caseEnd}" pattern="MM/dd/yyyys"/></label>
					</div>
				</div>
			</div>
		</div>
		<hr>
		
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header">Information on the Person Reporting the Abuse(if different than above):</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Relation to the Abused Person</label>
					<label class="form-control">${caseInfo.reportedBy.relation}</label>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">If other, please explain</label>
					<label class="form-control">${caseInfo.reportedBy.relationOther}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">First Name</label>
					<label class="form-control">${caseInfo.reportedBy.firstName}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Middle Name</label>
					<label class="form-control">${caseInfo.reportedBy.middleName}</label>
				</div>
			</div>
			<div class="col-sm-4">
				<div class="form-group no-margin-hr">
					<label class="control-label">Last Name</label>
					<label class="form-control">${caseInfo.reportedBy.lastName}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label">Street Address</label>
					<label class="form-control">${caseInfo.reportedBy.streetAddress}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">City</label>
					<label class="form-control">${caseInfo.reportedBy.city}</label>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">State/Province</label>
					<label class="form-control">${caseInfo.reportedBy.state}</label>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Zip/Postal Code</label>
					<label class="form-control">${caseInfo.reportedBy.zip}</label>
				</div>
			</div>
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Country</label>
					<label class="form-control">${caseInfo.reportedBy.country}</label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Phone Number</label>
					<label class="form-control">${caseInfo.reportedBy.telephone}</label>
				</div>
			</div>
			<div class="col-sm-6">
				<div class="form-group no-margin-hr">
					<label class="control-label">Email Address</label>
					<label class="form-control">${caseInfo.reportedBy.email}</label>
				</div>
			</div>
		</div>
		<hr>

		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Type of Abuse That Occurred(Check as many as apply)</label>					
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<label class="checkbox-inline">
						${typeIds }
					</label>			
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-3">
				<div class="form-group no-margin-hr">
					<label class="control-label">Summary of Abuse That Occurred</label>				
				</div>
			</div>
			<div class="col-sm-9">
				<div class="form-group no-margin-hr">
					<textarea rows="3" class="form-control"  disabled name="summary">${caseInfo.summary} </textarea>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">
					Mental Health Facilities Were Involved With the Abuse:
					</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Facilities Where the Abuse Occurred</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<c:forEach var="facilityInfo" items="${caseInfo.facilityInfos }" varStatus="status">  
				<div class="col-sm-6">
					<div class="row">
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">#${status.count} - Facility Type</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.type}</label>
							</div>
						</div>
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">If other, please explain</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.typeOther}</label>
							</div>
						</div>
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">Facility Name</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.name}</label>
							</div>
						</div>
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">Street Address</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.streetAddress}</label>
							</div>
						</div>
						<div class="col-sm-1">
							<div class="form-group no-margin-hr">
								<label class="control-label">City</label>
							</div>
						</div>
						<div class="col-sm-4">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.city}</label>
							</div>
						</div>
						<div class="col-sm-3">
							<div class="form-group no-margin-hr">
								<label class="control-label">State/Province</label>
							</div>
						</div>
						<div class="col-sm-4">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.state}</label>
							</div>
						</div>
						<div class="col-sm-2">
							<div class="form-group no-margin-hr">
								<label class="control-label">Zip/Postal Code</label>
							</div>
						</div>
						<div class="col-sm-4">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.zip}</label>
							</div>
						</div>
						<div class="col-sm-2">
							<div class="form-group no-margin-hr">
								<label class="control-label">Country</label>
							</div>
						</div>
						<div class="col-sm-4">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.country}</label>
							</div>
						</div>
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">Phone Number</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${facilityInfo.telephone}</label>
							</div>
						</div>
					</div>
				</div>			  
			</c:forEach>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Doctors Were Involved With the Abuse：</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Doctors Who Were Involved With the Abuse</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<c:forEach var="doctorInfo" items="${caseInfo.doctorInfos }" varStatus="status">
				<div class="col-sm-6">
					<div class="row">
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">#${status.count} - Doctor First Name</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${doctorInfo.name}</label>
							</div>
						</div>
					</div>
					<div class="row">
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">Doctor Type</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${doctorInfo.docType}</label>
							</div>
						</div>
					</div>
					<div class="row">
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">Street Address</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${doctorInfo.streetAddress}</label>
							</div>
						</div>
					</div>
					<div class="row">
						<div class="col-sm-1">
							<div class="form-group no-margin-hr">
								<label class="control-label">City</label>
							</div>
						</div>
						<div class="col-sm-4">
							<div class="form-group no-margin-hr">
								<label class="form-control">${doctorInfo.city}</label>
							</div>
						</div>
						<div class="col-sm-3">
							<div class="form-group no-margin-hr">
								<label class="control-label">State/Province</label>
							</div>
						</div>
						<div class="col-sm-4">
							<div class="form-group no-margin-hr">
								<label class="form-control">${doctorInfo.state}</label>
							</div>
						</div>
					</div>
					<div class="row">
						<div class="col-sm-2">
							<div class="form-group no-margin-hr">
								<label class="control-label">Zip/Postal Code</label>
							</div>
						</div>
						<div class="col-sm-4">
							<div class="form-group no-margin-hr">
								<label class="form-control">${doctorInfo.zip}</label>
							</div>
						</div>
						<div class="col-sm-2">
							<div class="form-group no-margin-hr">
								<label class="control-label">Country</label>
							</div>
						</div>
						<div class="col-sm-4">
							<div class="form-group no-margin-hr">
								<label class="form-control">${doctorInfo.country}</label>
							</div>
						</div>
					</div>
					<div class="row">
						<div class="col-sm-5">
							<div class="form-group no-margin-hr">
								<label class="control-label">Phone Number</label>
							</div>
						</div>
						<div class="col-sm-7">
							<div class="form-group no-margin-hr">
								<label class="form-control">${doctorInfo.telephone}</label>
							</div>
						</div>
					</div>
				</div>
			</c:forEach>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Were Psychiatric Drugs Prescribed?</h1></label>
					<select class="unRender" disabled>
						<option>${caseInfo.drugsPrescribed}</option>
					</select>
				</div>
			</div>
		</div>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">What Psychiatric Drugs Were Prescribed?</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<c:forEach var="drugName" items="${drugNames }" varStatus="status">
				<div class="col-sm-1">
					<div class="form-group no-margin-hr">
						<label class="control-label">#${status.count}</label>		
					</div>
				</div>
				<div class="col-sm-3">
					<div class="form-group no-margin-hr">
						<label class="form-control">${drugName}</label>
					</div>
				</div>
			</c:forEach>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">Are You Working With an Attorney?</h1></label>
					<select class="unRender" disabled name="attorney.workWithAttorney">
						<option>${caseInfo.attorney.workWithAttorney}</option>
					</select>
				</div>
			</div>
		</div>
		<c:if test="${caseInfo.attorney.workWithAttorney == 'Yes'}">
			<div class="row">
				<div class="form-group no-margin-hr">
					<label class="col-sm-2 control-label">Attorney Name</label>
					<div class="col-sm-10">
						<label class="form-control">${caseInfo.attorney.name}</label>
					</div>
				</div>
			</div>
			<div class="row">
				<div class="form-group no-margin-hr">
					<label class="col-sm-2 control-label">Street Address</label>
					<div class="col-sm-4">
						<label class="form-control">${caseInfo.attorney.streetAddress}</label>
					</div>
					<label class="col-sm-2 control-label">City</label>
					<div class="col-sm-4">
						<label class="form-control">${caseInfo.attorney.city}</label>
					</div>
				</div>
				<div class="form-group no-margin-hr">
					<label class="col-sm-2 control-label">State/Province</label>
					<div class="col-sm-4">
						<label class="form-control">${caseInfo.attorney.state}</label>
					</div>
					<label class="col-sm-2 control-label">Zip/Postal Code</label>	
					<div class="col-sm-4">
						<label class="form-control">${caseInfo.attorney.zip}</label>
					</div>
				</div>
				<div class="form-group no-margin-hr">
					<label class="col-sm-2 control-label">Country</label>
					<div class="col-sm-2">
						<label class="form-control">${caseInfo.attorney.country}</label>
					</div>
					<label class="col-sm-2 control-label">Phone Number</label>
					<div class="col-sm-2">
						<label class="form-control">${caseInfo.attorney.telephone}</label>
					</div>
					<label class="col-sm-2 control-label">Email Address</label>
					<div class="col-sm-2">
						<label class="form-control">${caseInfo.attorney.email}</label>
					</div>
				</div>
			</div>
		</c:if>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="col-sm-7 control-label">Would like assistance in getting an attorney to file charges or represent your case.</label>
					<div class="col-sm-1">
						<input type="checkbox" class="form-control" disabled
							<c:if test="${! empty caseInfo.attorney.assistanceAttorney}">
										checked="checked"
							</c:if>
						/>
					</div>
				</div>
			</div>
		</div>
		<hr>
		<div class="row">
			<div class="col-sm-12">
				<div class="form-group no-margin-hr">
					<label class="control-label"><h1 class="form-header" style="margin-bottom:10px; margin-top:10px">What Actions Are You Interested in Taking On This Case?</h1></label>
				</div>
			</div>
		</div>
		<div class="row">
			<c:forEach var="action" items="${actions }" varStatus="status">
				<div class="col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="checkbox-inline">
							<input type="checkbox" class="px" disabled checked="checked"> <span class="lbl">${action }</span>
						</label>			
					</div>
				</div>
			</c:forEach>
		</div>
		<c:if test="${! empty caseInfo.otherAction}">
			<div class="row">
				<div class="col-sm-12">
					<div class="form-group no-margin-hr">
						<label class="checkbox-inline">
							<input type="checkbox" class="px" disabled checked="checked"> <span class="lbl"><input type="text" id="otherActionInput" disabled="disabled" class="form-control" value="${caseInfo.otherAction }" placeholder="Other"></span>
						</label>			
					</div>
				</div>
			</div>
		</c:if>
		</form>



	
	<!-- / Form -->

<!-- Get jQuery from Google CDN -->
<!--[if !IE]> -->
	<script type="text/javascript"> window.jQuery || document.write('<script src="<%=contextPath%>/assets/javascripts/jquery-2.0.3.min.js">'+"<"+"/script>"); </script>
<!-- <![endif]-->
<!--[if lte IE 9]>
	<script type="text/javascript"> window.jQuery || document.write('<script src="<%=contextPath%>/assets/javascripts/jquery-1.8.3.min.js">'+"<"+"/script>"); </script>
<![endif]-->


<!-- Pixel Admin's javascripts -->
<script src="<%=contextPath%>/assets/javascripts/bootstrap.min.js"></script>
<script src="<%=contextPath%>/assets/javascripts/pixel-admin.min.js"></script>
<script src="<%=contextPath%>/assets/javascripts/select2.min.js"></script>

<script type="text/javascript">
	window.PixelAdmin.start([
		function () {
			$("#signup-form_id").validate({ focusInvalid: true, errorPlacement: function () {} });

			
		}
	]);
</script>

<!-- Javascript -->
	<script>var init = [];</script>
	<script>
    
		init.push(function () {

			var options2 = {
				orientation: $('body').hasClass('right-to-left') ? "auto right" : 'auto auto'
			}
			
		});
		window.PixelAdmin.start(init);
	</script>

